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What’s the normal rate though?
From the BBC article
Before June 2015, there were about two or three baby deaths a year on the neonatal unit at the Countess of Chester Hospital. But in the summer of 2015, something unusual was happening.
In June alone, three babies died within the space of two weeks.
Statistically it could happen. But concerns were raised at that point
The deaths were unexpected, so Dr Stephen Brearey, the lead consultant at the neonatal unit, called a meeting with the unit manager, Eirian Powell, and the hospital's director of nursing Alison Kelly.
Everything after that is a fail, in the sense that action could have been taken but was not. You can argue that the first three in quick succession couldn't be prevented; if a nurse wanted to do the same again tomorrow then it would be very hard to stop.
A doctor or nurse who accepts an instruction from management that puts patients at risk of harm is in clear breach of professional standards
I look forward to reading about the GMC hearings into the doctors who did follow those instructions and the doctors in management who issued them. I’m not going to hold my breath because I very much doubt the GMC will do anything
The reviews were looking to see if there was evidence of clinical incompetence not a murderer.
That’s not unreasonable. Medical murderers are fortunately rare. Clinical incompetence unfortunately is not.
Looking for clinical incompetence is not the same as looking for evidence of crime, so it’s not surprising that the reviews didn’t turn anything up.
I was thinking about this earlier today. I’m sure there is a similarity to sex abuse in the churches, at first it seems implausible that someone in that profession would want to harm others so alternative explanations seem much more likely. Bent cops are probably similar. To really put your head above the parapet you need not only to be morally right, but to be financially secure. Current protections don’t go anywhere near enough to protect those who could be morally more robust if they could afford to be. There are very few people at the top who are measured on “discovered and reported a crime” so it’s not the culture that cascades down.
most organisations (and this includes the nhs in Scotland despite TJs rose tinted glasses) have an immediately defensive response to anything vaguely resembling a complaint. I also think in Scotland we have a very limited view of fatality investigation. My gut feel is coroners may be better than the PF.
Treat with great suspicion anyone who says it could never happen in their organisation. There’s always the potential for a screw up, and that means there’s always someone who will have an interest it covering it up. Consciously or subconsciously people with malevolent intent will exploit those weaknesses.
most organisations (and this includes the nhs in Scotland despite TJs rose tinted glasses) have an immediately defensive response to anything vaguely resembling a complaint.
not always and the culture is changing but I tend to agree. I did not mean to give the impression I thought everything rosy up here - its just I know the Scots NHS procedures but I am not certain on the English ones
However the setup up here does remove one driver of the behaviour that causes the secrecy - the collaborative nature which means hospitals are not in competition
I am still in favour of "no fault" incident investigations as being the only way to discover the truth
There is the behaviour of assigning fault in everything. People don't want reviews and investigations because they are about finding out who messed up not what went wrong. The latter will/may pick up who messed up if that's the case but there's a lack of honesty if everyone is worried about how they will be affected.
People don’t want reviews and investigations because they are about finding out who messed up not what went wrong.
Actually from my understanding is most folk want to know why the incident happened and that it will not happen again. they generally do not want an individual punished. Its very rare in medical incidents that there is a single action that causes it.
but there’s a lack of honesty if everyone is worried about how they will be affected.
Which is why "no fault" needs to be the way forward
https://www.england.nhs.uk/patient-safety/incident-response-framework/
So this is English governments attempt to solve the issue. It was a top down instruction from central government about a year and a half ago, with tight deadlines for implementation. We all wondered what the trigger was at the time, and there was some ‘gossip’ as to what was behind it.
Some Trusts are still struggling to implement it now. Others have implemented it, but culture prevents it being effective.
Lots of talk about culture, yet to read one suggestion on how you actually start to tackle it.
There's an utter lack of transparency even internally, so no surprise that influences a toxic culture of blame & retribution. That in part is due to how HR personnel are bred via the CIPD, they're a threat to any kind of just culture. They should IMO be removed from any investigation loop.
It's why nothing ever changes, from an outsider's perspective people are scared because it would involve making very bold changes which would be unpopular.
As a result things will get much worse before they get better. We can cry about Tory underfunding but the organisation will be destroyed as a result of its own behaviour before privatisation.
I have - "no fault" incident investigations. that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes
also get rid of the fake market in England which produces pressures to be secretive by seniors
I have – “no fault” incident investigations. that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes
As is the way, an easy statement to make. Do you have any idea how you implement, enforce and assure such a thing?
I'd lift the MAA model a drop it on the NHS in a heartbeat, but it doesn't like outsiders so would be unpopular, challenging and costly.
All the reasons why it would never happen.
Better training for managers as well.
also get rid of the fake market in England
That already happened some time ago. (about 2017 under the Stevens reforms)
Sorry and another edit: The payment for results (provider/commisioning) stopped in about 2019 or so.
its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources? Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up
“no fault” incident investigations. that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes
It's frustrating to read this as an outsider to the health industry. That people are still fearing disciplinary proceedings for genuine mistakes is a massive problem in 2023.
FWIW, aviation moved from "no blame" to "just culture" some time ago. This is different in that it acknowledges that human errors can occur even in well-designed systems. There may be instances where individuals need to be held accountable for their actions if they demonstrate wilful negligence or consciously disregard safety protocols. This approach seeks to strike a balance between encouraging reporting and learning, and ensuring that individuals are responsible for their actions when they knowingly violate safety procedures.
To put the difference in monitoring into perspective, if you take a flight in the UK the contents of the "black box" (simplifying a bit here) will be downloaded wirelessly to the airline's HQ before you even get through the terminal. This is then automatically analysed and anything unusual will be flagged up (there are thousands of parameters and triggers). This then reviewed by another line pilot who is emphatically not management.
Outside of this system, every single flight finishes with a discussion about what happened and what can be improved upon.
Trends from this automatic analysis are identified and then directly targeted during six-monthly training cycles. We have two safety magazines published each month. Airbus have an enormous publicly accessible training library packed with videos. We have free access to the full flight simulators during off-hours.
As many others have highlighted the biggest problem in the NHS seems to be a culture of trying to protect the Trusts from admitting any error. I can actually completely understand this as an admission of error usually leads to legal action and as someone who was called as a professional witness a few years ago in a High Court case, it's a deeply unpleasant affair that I'd prefer not to go through again. Whether or not this has to be accepted as part of the job of working in health, I don't know.
I believe ( and think the resrearch backs this up) that actually most folk do not want legal action and huge compensation - they want candor about what happened and an understanding that steps will be taken to prevent it happening again
the omerta actually encourages folk to sue as its often the only way they get answers
its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources?
No it hasn't been like that for ages. The Provider/Purchaser split was a disaster from the get go (Landsley 2012) I don't think there's been legislation to actually take it off the the statue, but Stevens in 2017, and the long term plan in 2019 pretty much killed it. The only thing left is NHS Property I think
Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up
The first cases happened waaay back in 2015, so possibly that may have been the case then?
I raised a safety issue within the cycling industry, and got nothing but grief from many cyclists (especially on here), as well as being fobbed off by the relevant authority in open collusion with manufacturers.
So yeah, I can believe that such attitudes are widespread. It's not really about "people in power", it's about people who aren't prepared to face difficult decisions, don't like having their equilibrium disturbed.
Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up
Do remember that the Letby murders were in 2015 and 2016. What was the case / in place then may have changed 7 or 8 years later (IDK and have suspicions of course)
So it's entirely possible that some of the desire to not admit to failings, driven by quasi-competition, etc., may not be as strong now.
And back to 'no fault / no blame'
As i said previously, I don't like that phrasing. I get that people should be unafraid to raise failings and know they will not be automatically penalised for raising it, or unfairly scapegoated without listening to mitigations, etc. But if things happen because people do things wrong, whether by intent or incompetence, then they need to be accountable and dealt with properly. If that's eg: lack of training to perform a task then the cause is the lack of time / funding / recognition that training is needed, which is a failing by management. If it's wilful that they know how to do it and cut corners or whatever then that's on the person. It's not a free hit which 'no fault, no blame' makes it sound like. Doesn't mean that the book has to be thrown either, perfectly possible to have a review that identifies where the fault lies, maybe there is a sanction, but learnings are taken from it.
Honest mistakes should not mean disciplinary action. thats the crux. Its almost never one mistake anyway.
Do you want to prevent further incidents? In which case we need the facts given honestly. If people think they are going to be punished they will not be candid
What happens right now is folk slant their evidence and point the finger at each other.
Also, reputational damage is still damage. If folks with disease or need urgent care aren't coming to the hospital because they perceive it to be unsafe, not great care or whatever, then that's going to be bad for local healthcare. It's not an "at all costs" thing that needs to be the only thing senior management team care about certainly, but it absolutely should be something they consider and take care to try to protect. Whole Hospitals are rarely bad, it's more than likely going to be individual depts within the whole, but once 'word' gets out, it's difficult to be nuanced about it.
I am still in favour of “no fault” incident investigations as being the only way to discover the truth
criminal investigation seems to have got something resembling the truth. Now if others have helped cover that up should they be blameless in any “how did we not spot it sooner” investigation? I think most people would struggle with that. And that is the problem with Rail/Marine/Air accident style investigations, their focus is on preventing recurrence with the premise being that it was “an accident”, nobody intended it and everyone learning is better than trying to blame one person.
I’m not convinced that competition encourages cover ups either. The organisations least open to critique in my experience are effectively monopolies, especially those held in very high esteem by the public. Usually doing some “worthy” thing, and criticising the organisation is treated as saying the worthy thing they do is wrong. Genuine competition means incompetent organisations will often fail. Even the worst run NHS trusts don’t truely fail - the hospitals and staff don’t close. To be 100% clear I am not advocating for privatisation, but we should be aware that when a public service (schools, hospitals, fire services, police forces) are unable to fail they can become pretty toxic. Whilst the organisation can’t fail the individuals can and that’s where the self preservation culture stems from. Promotion comes not from finding the bad actors in the system but from outwardly presenting an image that everything is under control.
Do remember that the Letby murders were in 2015 and 2016. What was the case / in place then may have changed 7 or 8 years later (IDK and have suspicions of course)
I don't mean to pick on you particularly, but it's a convenient jumping-off point. This attitude gets trotted out time after time and it's just such a heap of stinking bullshit. People don't change, not much anyway, and behaviours get repeated time after time. We had it all with miscarriages of justice. "Oh, that was the 1970s, it was all different back then". "Oh, that police rapist was last year, we're different now". "Oh, back in the 1800s everyone thought slavery was just fine, we're more evolved now". 2015 is hardly the Dark Ages.
Ok, we did eventually outlaw slavery (after a century of campaigning). Change does happen, but it's slow and gradual and while so many people willingly acquiesce to abuse of power, abuse of power will continue.
A culture change is needed. IMO the no fault incident investigations are the key component in doing so.
It does not help that I have known a number of nurse managers who are totally ill informed in this sort of area and put the frighteners on the staff telling them they will be personally liable when actually they would not be
Better manager training is a key thing as well
Better manager training is a key thing as well
'Some' management would be a good place to start frankly. I don't know of any organisation quite like the NHS that has so few (and ill trained) managers in it.
So if you want truthful evidence and that evidence points to a failing, do they get off scot free because they raised it? I don't agree.
Hypothetical situation - a nearly serious incident where someone was working with solvents in a controlled space (ie behind access controlled doors with no people just coming and going)
The policies and procedures made it clear that when undertaking hazardous activities in this space (where RA shows residual risk > whatever) then user must not work alone. However it was manager discretionary what that meant - didn't mean the person had to have a second stood over them, could eg: have a open video call that someone external could view.
The worker set this up, but then also deviated from the experimental process and raised the lid of fume hood above working level because it was easier to access the kit. They were then overcome by fumes, sufficient to need medical care but not so bad they weren't able to raise alarm for themself.
Their overwatcher had gone off to make a cup of tea, got sidetracked on the way back and missed all the excitement.
This was investigated fully, and there were several failings leading to reprimands for the overwatcher (if you're given that job, do it properly) and in a formal warning (don't cut corners to save time, follow the process!). The only actual change made as a result is to interlock the fume hood to not allow it to be opened beyond the safe level. The rest was sufficiently robust procedures that folk just didn't follow, and consequently got 'punished' - rightly.
So it's not easy - if they'd known they'd get reprimands for this would they have raised it. It wasn't possible to cover up completely in this case because first aiders/hospital visit, but how serious the outcome was was only luck once the incident happened. Could have been more severe, equally could have been 'whoa, I went light headed there.....but my own stupid fault, better not tell anyone, lesson learned, put the lid down properly eh!'
There are two separate issues here I think - Risk management vs illegal acts by an individual
Safety and risk management - healthcare has a lot to learn from other industries. I've worked in a few (chemicals, pharma and now medical devices) where the structured risk assessments and continuous learning/improvement could and should be applied to healthcare. Healthcare (and mainly consultants) seem to think they are some unique and special flower that can't learn from any other industry. A level of honesty is required about deaths and incidents, some will happen, saying there should be zero is unhelpful you can't apply a lot of risk management tools with zero, probability doesn't work like that.
Willful illegal acts are something entirely different - these safety systems aren't set up to deal with that really. When working at a large chemical site with a very good safety record, one disgruntled employee sabotaged part of the plant (undid a pipe) and ended up spraying a colleague with caustic. All the risk management - design reviews, commissioning tests, scheduled maintenance...) couldn't prevent that
So if you want truthful evidence and that evidence points to a failing, do they get off scot free because they raised it? I don’t agree.
Depends on the failing. A punative approach does not work. To continue to do the same thing and expect a different outcome?
the failing may require nothing, it may require retraining, if a criminal threshold is reached then obviously prosecution
what should not happen is honest mistakes leading to disciplinary
its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources?
In theory no. But the culture still very much intrenches this. Integrated Care Systems (ICS) have been setup to replace CCG's which were PCT's
The approach now is that we all share the love in a region ie we all work for the local population in the area. In our area this means some Trusts inherit other Trusts poor financial positions, which means they cannot spend where needed. Its currently creating more division and silo working in our corner of the world as Trust try to protect their own autonomy. I doubt its different anywhere else.
I believe ( and think the resrearch backs this up) that actually most folk do not want legal action and huge compensation – they want candor about what happened and an understanding that steps will be taken to prevent it happening again
the omerta actually encourages folk to sue as its often the only way they get answers
TJ - yes certainly in the only case where I’ve complained the aim was never compensation. The aim was that they make the treatment better for the next person. I don’t actually know if we succeeded because a lot of the response seemed to be about wearing you down until you give up, as well as telling me things didn’t happen I saw with my own eyes. It did get so frustrating that they were covering up what happened that it did make us think maybe we do need to sue them to get the attention this deserves. (FWIW this should have been a 10 minute debrief - how could we have made that better for this patient? Nothing they needed to do would have cost money or needed more people - they just needed to take a deep breath, take a step back and remember there’s a person lying on the bed.). In the end someone realised I wasn’t chasing a claim and promised to review their approach - no idea if they actually did
‘Some’ management would be a good place to start frankly. I don’t know of any organisation quite like the NHS that has so few (and ill trained) managers in it.
Agreed. A 1 hour interview isn't sufficient. Better training (mandated) to be an essential criteria at application apply for management roles would be a good place to start.
The MAA investigation model is top drawer and would provide the much needed transparency and assurance they would ensure accountability and responsible and fair outcomes. With an assurance framework to enable investigations to stand under scrutiny.
The other reason I raise it is because unlike their civilian counterparts military aviation does look at criminality as part of the process. So if there is deliberate nefarious acts then suitable action can take place. The NHS just culture approach does the same.
Some you you are applying your own subjective interpretation of what TJ is saying, he's saying no fault investigation the outcome and fault/blame/accountability should come as a result of an open and impartial investigation. That requires independence and autonomy, something staff investigating within their own trust do not truly have.
Errors, such as those flagged on DATIX should be shared widely. Yes, it's uncomfortable but a lack of transparency creates ambiguity, ambiguity can be exploited and/or create conditions for mistakes to thrive.
The organisation is institutionally disingenuous and as another poster has said, excuses have to stop being made.
Someone who failed to do their job in 2015 is unlikely to have changed their behaviour.
Depends on the failing. A punative approach does not work. To continue to do the same thing and expect a different outcome?
the failing may require nothing, it may require retraining, if a criminal threshold is reached then obviously prosecution
what should not happen is honest mistakes leading to disciplinary
Doesn't have to be criminal, in the (hypothetical I must stress!) example above no law was broken - although technically the HSE could contest that in the serious cases - but clear policies and practices were. And there's a grey area between wilful and pure accident where many other factors come in - including competence and training, etc.
Honestly, you don't need training or competence to be able to have a window open on your PC where you can see a co-worker. You don't need to be trained to be told not to wander off and forget you were doing it when someone at the kitchen distracts you. At no point did they go 'I know I'm supposed to be keeping watch on Dave but **** it, I'm going to talk to Simon about the football'
But it's not 'an accident' either - and to not allow John to get an appropriate telling off for not doing his job properly - would he do it differently next time? I bloody hope so.
Here a comparison of two different approaches. For balance:
The Military Aviation model:
The NHS Model:
One of these is a guide that lacks any conversation about culpability and leaves that in the hands of HR, the other a mandated, transparent, and assured process that shares findings widely.
Which would give you more confidence in being open and honest?
theotherjonv
I would say in the case you mention its a training / competency issue not disciplinary and should be dealt with as such
Really? You're talking of the watcher, not the actual experimenter? How much training / competence do you need to understand how the virtual buddying system works....... keep an eye on Dave to make sure they don't hurt themselves.
The experimenter - I'm quite low on sympathy for. If I put that through the flowcharts above I'd get to (MOD) rule breaking for selfish (their own time) gain, or organisational gain (possibly.....although any time saved for the benefit of the org would be lost 10x over in the clear up)
or via the NHS one - kicks right at foresight test: singling out individual unlikely to be appropriate (agree, but a lessons learned for the Org would be) - and actions for the individual (but as R-M has said, unclear from that what they might be). They don't need training, other than training to know not to break the rules in place for their safety!
Someone who failed to do their job in 2015 is unlikely to have changed their behaviour.
Depends - possibly culture has changed in the admin management area, possibly not, but if any of them reflect and think they got it right and they'd do it all again then I don't know what to think.
And the clinical management - I think they too would have to reflect. Seems to me (and I know I'm not an inquest and not in possession of all facts) that there was hard evidence in the form of eg: Insulin levels from pretty early on that they didn't read or take note of. I'd also reflect that the lab tech who ran the bloods could / should have spotted high levels and flagged, or if they are simply churning out results by pressing buttons that the computer could easily be updated to flag if the insulin is synthetic (absence of the co-factor)
The Provider/Purchaser split was a disaster from the get go (Landsley 2012) I don’t think there’s been legislation to actually take it off the the statue, but Stevens in 2017, and the long term plan in 2019 pretty much killed it. The only thing left is NHS Property I think
The NHS internal market is very much alive and well along with the provider / purchaser split. All that has happened is that ICBs now commission, rather than CCGs and PCTs before them (which look remarkably similar to PCTs). There is still a price list for everything https://www.england.nhs.uk/pay-syst/nhs-payment-scheme/
Turns out I was wrong about my consultant colleagues having access to independent medico-legal advice, some may do, but it's not mandatory for them to have it, unlike us GPs.
https://www.bbc.co.uk/news/uk-england-merseyside-67006930
Lucy Letby: Corporate manslaughter probe at Chester hospital
I am not sure what 'Corporate Manslaughter' is ie what the test is. Hopefully might be the kick up the arse hospital management need
Unfortunately my experience of the threat of corporate manslaughter is that managers are so shit scared of it they spend an inordinate amount of time making sure that individual employees will get the blame should anything happen. (Rather than making sure it doesn’t happen in the first place)
I am not sure what ‘Corporate Manslaughter’ is ie what the test is.
it needs to be a relevant organisation (nhs trusts seem to qualify) it needs to have a clear duty of care (that would be hard to argue against) and there has to have been a failing in that duty so serious that it merits criminality. Those are my words not the legislation. interestingly there’s no need to the organisation to have had foresight that death might result so on paper it seems easier to prosecute but I think it’s exceptionally rarely used because it is very hard to prove. I’ve heard enough to know why they are pursuing this - but I think it’s far from certain it will succeed if the trust pleads not guilty - all they need to do is cast doubt that as an organisation they acted as best they could and were getting advice from some of their more junior managers that all was ok and I think they may have a defence because it’s only the actions/inaction of the most senior managers or the organisations wider systems that fall under corporate manslaughter.
Hopefully might be the kick up the arse hospital management need
unfortunately I won’t - the result of corporate rather than “personal” manslaughter is that the trust not the individuals will get a massive fine. Likely if there is a conviction the judge ends up limiting the fine as it only hurts patients. The kick they need is personal liability for their failings; although I suspect that will make many, more reluctant to make decisions and life harder for people in the nhs rather than recognising that it was about bad people not doing the basics right.
I nearly gave expert witness evidence at a corporate manslaughter case, until the defence understood what I was likely to say and that it would likely be more beneficial to the prosecutor. That case took 6 or 7 years to get before the courts and the crown backed down at the 11th hour and accepted a much less serious H&SAW act charge. Having seen the evidence - it looked like a straightforward case - the company was at fault, but the issue was how high up the tree could they show involvement in the decision making and that it was not a “rogue employee” ignoring policy. (My evidence was not relevant to that but would have been an attempt by the defendant to suggest they perhaps didn’t cause the death at all).
All the management should have the same professional acountability as doctors and nurses and the same legal obligations. It concentrates the mind knowing you could be answerable in court.
Criminal charges are exactly the opposite of a culture of safety.
So is “accountability”.
A culture of safety is one in which people are encouraged to acknowledge and share their mistakes for the benefit of the organisation.
Threatening them doesn’t make this happen.
Correct Kramer
However its also right that you should be able to be called to explain your actions in a coroners court or similar forum. The threat of criminal sanctions should not be there unless you are not truthful or your behaviour was deliberate or malicious. There should be no criminal sanction for honest mistakes.
It concentrates the mind knowing you could be answerable in court.
it might very well do, but given the amount of clear malpractice that the indemnity unions defend every year, I don't think it's making much difference.
A culture of safety is one in which people are encouraged to acknowledge and share their mistakes for the benefit of the organisation
But Letby was deliberately malevolent, it has nothing to do with mistakes that the unit made, so then you look to the mistakes that the upper management made. To me it's clear only with the benefit of hindsight that the management of this hospital made the wrong call not to involve the police earlier, but you can see the perfectly reasonable steps they took to arrive at that decision, and in all of these types of cases, some of time, the wrong decision is going to be made, and it'll happen again. Because like this case, that you have a serial killer working at your hospital is rarely going to be the first and correct decision you arrive at when there are unexpected deaths on a ward..
wrong thread ignore me.
in the Letby case there are still ( with hindsight) clear errors on a number of peoples parts.
If we want to stop errors happening and to do so we require candour. If people are afraid of being blamed and criminal sanctions then we will not get candour